We report the use of diagnostic laparoscopy as an alternative to laparotomy in the investigation of infants with bile stained vomiting and inconclusive upper gastrointestinal contrast study.
Casenote review of all infants in whom laparoscopy was performed during 2016-2017 to investigate for possible malrotation.
Four infants, gestational age 40-41weeks, weight 3.3-4.9kg, age of presentation day 1-2 of life are included. All presented with bilious vomiting, warranting a definitive causative pathology of intestinal malrotation to be excluded. All four infants underwent upper GI contrast study, with three also having abdominal ultrasound to assess the orientation of the superior mesenteric vessels (SMVs). In all 4 infants upper GI contrast study could not conclusively exclude a diagnosis of malrotation. Ultrasound revealed normal SMV orientation in two and abnormal in one.
Laparoscopy was performed using a 5mm umbilical port and two 3 mm stab incisions. The small intestine was run proximally and distally to exclude the presence of midgut volvulus. In all cases the DJ flexure was positively identified in the left upper quadrant to the left of the midline with the proximal duodenum passing behind the root of the mesentery in a fixed retroperitoneal position and the caecum was positively identified in the right lower quadrant and found to be fixed. All infants recovered without complication and were discharged within 48 hours.
Laparoscopy is an excellent modality for further investigation of infants in whom intestinal malrotation cannot be formally excluded using non-invasive techniques. The positive identification of DJ flexure and caecum in correct anatomical sites, both fixed to the posterior abdominal wall, provides adequate reassurance of low risk of volvulus and avoids a full laparotomy. We recommend diagnostic laparoscopy in cases of inconclusive upper GI contrast study.